Thursday, July 05, 2012

The Destructiveness of Measures

A little box pops up before him asking if he asked the patient about the exercise. He mumbles something under his breath, clicks a little box beneath the question, then moves on.

This is what medicine has become: a series of computer queries and measures of clicks. It must be measurable, quantifiable, and justifiable or it didn't happen.

Do they ask if I asked them about if they used cocaine? Of course not: too politically incorrect.
Do they ask if I really listened to their heart? Of course not - this activity is not a paid activity.
Do they ask about the myriad of phone calls and e-mails to arrange for a procedure? Nope.
Do they measure my time with the patient when I go back to see them on the same day? Nope- not paid for.

So what's the motivation for doctors to be doctors? Are we retraining our doctors from care-givers to data providers? What are we losing in turn?

Today, an excellent opinion piece by Daniel Henniger appeared in today's Wall Street Journal. In it, he references an important article by Drs. Christine Cassel and Sachin H Jain published in the June 17th issue of JAMA entitled "Assessing Individual Physician Performance: Does Measurement Suppress Motivation." Cassel and Jain are two shapers of the Pay-for-Performance movement but acknowledge the danger this movement has on physician behavior:

Overstating the value of discrete quality measures has the potential to demotivate and demoralize physicians who appropriately view their job as much more than simply meeting a standardized measure set.

This point cannot be overemphasized.

Doctors are losing their motivation to diagnose in favor of sitting at a computer. Doctors, I also dare say, are losing their skills in favor of sitting at a computer. Clicking buttons has such importance to health care systems that these performance measures are being linked, in part, to doctors' salaries. As a result, young doctors are losing their complex problem solving skills in favor of making sure they click on every result that comes to their inbox, lest they be seen as nonproductive. This, you see, is what matters to employers.

We are reshaping medicine away from the bedside to the computer.

We'd better understand the damage this shift is causing before our young physicians of tomorrow don't know any better.

4 comments:

Anonymous
said...

Destructiveness of measures! It depends upon which side you are on. If you are a payer and can find a reason (any reason) to lower reimbursement, call registries and forced data dumping a major success. Remember the phrase VALUE BASED PURCHASING. There can only be value in a measured result. Documenting your failure to adequately control a complex biologic system is one step closer to the valhalla of lowered medical costs.

Who else is going to benefit from this takeover of the databases/registries? Could it be...the ACC. Have you heard of mandatory reporting to an intermediary? Who do you think has assumed that role? You just thought that they defended doctors who cut the legs off of patients making $50-60,000. See meaningful use part II (the revenge of meaningful use) and learn that you will be systematically devalued unless you comply. Then again, you EPs already learned that with the investigation by the DOJ. It may take a couple EPs being perp walked before you docs figure this thing out.

Documentation is by no means the physicians friend. We have been held to requiresments for years that require a certain level of documentation to justify payment. We now enter the era where this is further compounded by the need to document even more steps so that we will not be penalized with diminished reimbursement (is it a tax or a penalty?!). Most of it isgarbage that is being generated, since it is generated by the provider who has an inherent bias in what gets reported and how. It will likely add little to improvement in care or patient safety and may actually be harmful by distracting providers from more important tasks. Just like EMRs, little proof that they save lives (but say it enough times and it becomes true) and certainly no proof that they decrease cost. Reams of data that will be analyzed may offer some insights, but I am not expecting the transformation of medicine we are being sold. As best as I can tell, the only cost savings are from slowing physicians down to the point they cannot see as many patients. Therefore, less bills sent to Medicare!!

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.